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Jefferson County Health Assesment 2016
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1.
In what zip code is your place of residence?
66054
66060
66066
66070
66073
66079
66088
66097
66512
2.
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
3.
What is your identifying gender?
Male
Female
Transgender
Other (please specify)
4.
Choose one ethnic identity.
Hispanic / Latino
Not Hispanic / Latino
5.
Choose one or more racial identities (regardless of ethnicity).
White
Asian
Black or African American
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
Prefer not to answer
Other (please specify)
6.
Indicate your annual take home pay range.
Less than $25,000
$25,000 - $49,999
$50,000 - $74,999
Over $75,000
7.
How many people live in your household?
1
2
3
4+
8.
Of those people identified in the above question, how many are dependents?
1
2
3
4+
None
9.
In which county do you work?
Atchison
Douglas
Leavenworth
Jefferson
Shawnee
Other (please specify)
10.
I use these services within Jefferson County more than 50% of the time. (select all that apply)
Banking
Dining Out
Entertainment
Medical Care
Physical Activity / Recreation Center
Purchase Clothing
Purchase Gasoline
Purchase Vehicle
Vehicle Maintenance
None
11.
What television station(s) do you get your news from? (select all that apply)
WIBW-13 (CBS)
KCTV-5 (CBS)
KSNT-27 (NBC)
KSHB-41 (NBC)
KTKA-49 (ABC)
KMBC-9 (ABC)
WDAF-4 (FOX)
I don't watch television.
12.
How do you stay up to date with current events and news? (select all that apply)
Newspaper
Online Newspaper
Television
Facebook
Twitter
YouTube
Flyers around town
Internet
Other (please specify)
13.
What newspaper(s) do you read? (select all that apply)
Oskaloosa Independent
Valley Falls Vindicator
Leavenworth Times
Topeka Capital Journal
Atchison Globe
Lawrence Journal World
I don't read the newspaper.
Other (please specify)
14.
If jobs were available in Jefferson County, would you work in Jefferson County?
Yes
No
Undecided
15.
What is your career category?
Agriculture
Banking
Construction
Education
Government
Healthcare
Sales
Technology
Other (please specify)
16.
How would you describe your overall health?
Excellent
Very Good
Good
Fair
Poor
17.
Are you able to visit a doctor when needed in Jefferson County?
Yes (proceed to question #19)
No
18.
If you answered "NO" to question #17, choose all that apply.
No appointment available
Can't afford it
Can't take time off work
No transportation
No specialist for my condition
I use healthcare outside of Jefferson County
Other (please specify)
19.
What type of healthcare coverage do you have?
Medicare
Medicaid / Kancare ( Amerigroup, United Healthcare, Sunflower)
Commercial Health Insurance (Humana, Blue Cross Blue Shield, United Healthcare, Aetna, Signa)
No Healthcare
Other (please specify)
20.
Select the challenges / concerns that apply to YOU and YOUR HOUSEHOLD. (select all that apply)
Alcohol overuse
Underage alcohol consumption
Illegal drug use
Prescription drug overuse
Tobacco use
Underage tobacco use
Suicide
Accidental death/injury
Traffic injury
Transportation
Economic growth
Unemployment
Affordable housing
Commute to work
Access to healthcare
Access to safe, clean drinking water
Access to healthy fruits and vegetables
Affordable childcare/preschool
Domestic / Child abuse
Infant mortality
Lack of immunization compliance
Overweight / Obesity
Access to physical activity
Stroke
Heart problems/concerns
High blood pressure
Diabetes
Cancer
Arthritis
Lung disease (COPD)
None
21.
Which of the following topics do you think are CONCERNS that need to be addressed in Jefferson County?
Alcohol overuse
Underage alcohol consumption
Illegal drug use
Prescription drug abuse
Tobacco use
Underage tobacco use
Suicide
Accidental death/injury
Traffic injury
Transportation
Economic growth
Unemployment
Affordable housing
Commute to work
Access to healthcare
Access to safe, clean drinking water
Access to healthy fruits and vegetables
Affordable childcare / preschool
Domestic / Child abuse
Infant mortality
Lack of immunization compliance
Overweight / Obesity
Access to physical activity
Stroke
Heart problems/concerns
High blood pressure
Diabetes
Cancer
Arthritis
Lung disease (COPD)
22.
What additional health services need to be offered to meet health challenges in you community?
23.
Choose all statements below that apply to you:
I exercise at least 3 times per week.
I eat at least 5 servings of fruits and vegetables each day.
I eat fast food more than once per week.
I smoke cigarettes.
I chew tobacco.
I use illegal drugs.
I abuse or overuse prescription drugs.
I consume more than 4 alcoholic drinks (if female) or 5 (if male) per day.
I use sunscreen or protective clothing for planned time in the sun.
I receive a flu shot each year.
I have access to a wellness program through my employer.
I protect myself from sexually transmitted infections.
None of these apply to me.
24.
Which of the preventative procedures have you had in the past 12 months? (select all that apply)
Mammogram (if female)
Pap Smear (if female)
PSA testing (if male)
Flu Shot
Colonoscopy
Rectal Exam
Blood Pressure Check
Blood Sugar Test
Skin Cancer Screening
Cholesterol Screening
Bone Density Test
Dental Cleaning/Dental X-rays
Physical Exam
Pneumonia Vaccine
Tetanus shot every 10 years
Sexually Transmitted Infection Testing
HIV Testing
None of the above
25.
Do you want or need any of the preventative services listed above?
Yes
No
26.
If "yes", why have you not received those services?
Time
Access
Cost
Other (please specify)
27.
The following are concern(s) that I have about Jefferson County:
Centralized Hospital
Recreation Center
Public Transportation
Affordable Housing
Increase in Employment Opportunity
None
28.
Other Comments: